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Berger L, Grimm A, Sütterlin M, Spaich S, Sperk E, Tuschy B, Berlit S. Major complications after intraoperative radiotherapy with low-energy x-rays in early breast cancer. Strahlenther Onkol 2024; 200:276-286. [PMID: 37591980 DOI: 10.1007/s00066-023-02128-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/23/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE To describe and analyze major local complications after intraoperative radiotherapy (IORT) with low-energy x‑rays during breast-conserving surgery (BCS) in early breast cancer. METHODS Ten women out of 408 who were treated with IORT between 2002 and 2017 and subsequently developed a severe local complication requiring surgical intervention were retrospectively identified and analyzed. Demographic, clinical, and surgical parameters as well as complication characteristics and treatment methods were evaluated. RESULTS At initial presentation, eight patients (80%) showed redness, six (60%) seroma, six (60%) wound infection, six (60%) suture dehiscence, and four (40%) induration of the former surgical area. Hematoma and necrosis were observed in one case (10%) each. Time interval until appearance of the first symptoms ranged from directly postoperative until 15 years postoperatively (median 3.1 months). Initial treatment modalities comprised antibiotic therapy (n = 8/80%) and transcutaneous aspiration of seroma (n = 3/30%). In the majority of patients, smaller surgical interventions (excision of a necrotic area/fistula [n = 6/60%] or secondary suture [n = 5/50%]) were sufficient to overcome the complication, yet larger interventions such as complex flap surgery and mastectomy were necessary in one patient each. CONCLUSION IORT is an efficient and safe treatment method as < 2.5% of all IORT patients experienced major local complications. However, it seems to pose the risk of causing severe local complications that may require lengthy and burdensome treatment. Thorough preoperative counseling, implementation of recommended intraoperative precautions, and high vigilance for first symptoms of complications during follow-up appointments are necessary measures.
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Affiliation(s)
- Laura Berger
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Anja Grimm
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Marc Sütterlin
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Saskia Spaich
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Benjamin Tuschy
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Sebastian Berlit
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Tutar B, Esen İçten G, Altınok A, Eröz S, Beşe N, Uras C. Comparison of mammography and ultrasound findings in the follow-up of patients with breast cancer treated with segmental mastectomy followed by intraoperative electron radiotherapy versus external whole breast radiotherapy. Diagn Interv Radiol 2023; 29:761-770. [PMID: 36994946 PMCID: PMC10679565 DOI: 10.4274/dir.2023.211218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 01/10/2023] [Indexed: 03/22/2023]
Abstract
PURPOSE This study aims to describe imaging findings in patients treated with intraoperative electron radiotherapy and compare them with those detected in patients treated with external whole breast radiotherapy (WBRT). METHODS The study population consisted of 25 patients who received intraoperative radiotherapy [IORT (21 Gy)] as single-dose radiotherapy and a control group of 25 patients who received WBRT at the same institution. Mammography and ultrasound (US) findings were divided into three groups: minor, intermediate, and advanced. On mammography, mass lesions were considered advanced, and asymmetries or architectural distortions were considered intermediate. Oil cysts, linear scars, and the increase in parenchymal density were considered minor findings. On US, irregular non-mass lesions were considered advanced, and circumscribed hypoechoic lesions or planar irregular scars with shadowing were considered intermediate. Oil cysts, fluid collections, or linear scars were considered minor findings. RESULTS On mammography, skin thickening (P = 0.001), edema (P < 0.001), increased parenchymal density (P < 0.001), dystrophic calcifications (P = 0.045), and scar/distortion (P = 0.005) were significantly more common in the WBRT group. On US, irregular non-mass lesions, which made interpretation considerably difficult, were significantly more common in the IORT group (P = 0.004). Dominant US findings were fluid collections and postoperative linear or planar scars in the WBRT group. Minor findings were more common in low-density breasts, and major findings (intermediate and advanced) were more common in high-density breasts on both mammographies (P = 0.011) and US (P = 0.027) in the IORT group. CONCLUSION Ill-defined non-mass lesions detected on US in the IORT group have not been defined previously. Radiologists should be aware of these lesions because they can be confusing, especially in early follow-up studies. This study has found that minor findings are seen more frequently in low-density breasts, while major findings are more common in high-density breasts in the IORT group. This has not been reported before, and further studies with more cases are needed to verify these results.
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Affiliation(s)
- Burçin Tutar
- Clinic of Radiology, Acıbadem Maslak Hospital, İstanbul, Turkey
| | - Gül Esen İçten
- Department of Radiology, Acıbadem University, Senology Research Institute, İstanbul, Turkey
| | - Ayşe Altınok
- Clinic of Radiation Oncology, Bahçelievler Medical Park Hospital, İstanbul, Turkey
| | - Seda Eröz
- Clinic of Radiation Oncology, Acıbadem Maslak Hospital, İstanbul, Turkey
| | - Nuran Beşe
- Department of Radiation Oncology, Acıbadem University, Senology Research Institute, İstanbul, Turkey
| | - Cihan Uras
- Department of Breast Surgery, Acıbadem Mehmet Ali Aydınlar University, Research Institute of Senology, İstanbul, Turkey
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Nafissi N, Meshkati Yazd SM, Shahriarirad R, Zangeneh S, Ghorbani S, Farazmand B, Karoobi M, Mirzaei HR. Postoperative cosmetic outcome of intraoperative radiotherapy in comparison to whole breast radiotherapy in early stage breast cancer; a retrospective cohort study. BMC Cancer 2023; 23:9. [PMID: 36597031 PMCID: PMC9811768 DOI: 10.1186/s12885-022-10468-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/21/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In this study, we aim to evaluate the cosmetic outcome differences between Intraoperative electron beam radiation therapy (IOERT) and whole breast radiotherapy (WBR) with further investigation of boosted IOERT. METHODS This retrospective cohort study was conducted in two referral centers in Tehran, Iran. 116 women aged 30 to 79 with early-stage breast cancer (T0-2N0-1M0) eligible for breast conservation were divided into two groups of 58 based on the intervention they received, and further subgroups were defined based on receiving boosted IOERT. Patients in both groups underwent breast conservation surgery and those in the IOERT group received either a 21 Gy radical dose (radical IOERT) or 12 Gy boosted electron beam radiotherapy and a routine fractionated dose of 50 Gy in 25 sessions of WBR (boosted IOERT). Those in the WBR group were administered 50Gy in 32 sessions. Physician-assessed cosmetic outcome was defined as the primary result and incidence of fat necrosis and fibrosis and post-operative chronic pain were secondary outcomes. RESULTS Post-operative cosmetic outcome scores and chronic pain, showed no significant difference between the two groups. The median cosmetic score in both groups was 9. Fat necrosis and fibrosis had significantly higher rates in the IOERT group (P. VALUE 0.001). However, the majority (21/34 or 61.8%) of this complication was observed in the boosted IOERT subgroup and no statistical significance was recorded between the radical IOERT subgroup and the WBR group. CONCLUSIONS In early-stage breast cancer treatment, radical IOERT has noninferiority compared to WBR in terms of cosmesis. Regarding fat necrosis and fibrosis, boosted IOERT was associated with higher rates in comparison to other groups. Therefore, radical IOERT seems to be a better treatment option for selected patients.
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Affiliation(s)
- Nahid Nafissi
- grid.411746.10000 0004 4911 7066Department of Breast, Rasoul Akram Hospital Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Mostafa Meshkati Yazd
- grid.411705.60000 0001 0166 0922Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, 01136746911 Iran
| | - Reza Shahriarirad
- grid.412571.40000 0000 8819 4698Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran ,grid.412571.40000 0000 8819 4698Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saba Zangeneh
- grid.411135.30000 0004 0415 3047Fasa University of Medical Sciences, Fasa, Iran
| | - Sahar Ghorbani
- grid.411746.10000 0004 4911 7066Department of Breast, Rasoul Akram Hospital Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Borna Farazmand
- grid.411705.60000 0001 0166 0922Radiation Oncology Research Center, Iran Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Karoobi
- grid.411705.60000 0001 0166 0922Department of Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, 01136746911 Iran ,grid.412571.40000 0000 8819 4698Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran ,grid.412571.40000 0000 8819 4698Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Mirzaei
- grid.411600.2Cancer Research Center, Shohadae Tajrish Hospital, Department of Radiation Oncology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Weinzierl A, Schmauss D, Harder Y. [The Significance of Oncoplastic Breast Reconstruction After Tumorectomy in Surgical Breast Cancer Therapy]. HANDCHIR MIKROCHIR P 2022; 54:305-313. [PMID: 35944535 DOI: 10.1055/a-1773-0968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Breast-conserving therapy (BCT), meaning tumorectomy in combination with systemic therapy and locoregional radiation therapy has become the preferred method to treat early-stage breast cancer. With excellent long-term recurrence-free and overall survival rates, breast surgeons today must deliver du- rable and aesthetically appealing results that guarantee a good quality of life to meet the high patient expectations. Oncoplas- tic breast surgery (OPBS) is an innovative approach to improve the overall results of BCT. Often carried out by a team of a plastic surgeon and an oncologic breast surgeon, OPBS can actively prevent breast deformities without compromising oncological safety. In the following, an overview of the principles and techniques of oncoplastic breast surgery will be given due to its ever-increasing significance and its advantages and dis- advantages will be discussed in the context of reconstructive breast surgery.
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Affiliation(s)
- Andrea Weinzierl
- Institut für Klinisch-Experimentelle Chirurgie, Universität des Saarlandes, Homburg/Saar, Deutschland
| | - Daniel Schmauss
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano (ORL), Ente Ospedaliero Cantonale (EOC), Lugano, Schweiz.,Fakultät der Biomedizinischen Wissenschaften, Università della Svizzera Italiana, Lugano, Schweiz
| | - Yves Harder
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano (ORL), Ente Ospedaliero Cantonale (EOC), Lugano, Schweiz.,Fakultät der Biomedizinischen Wissenschaften, Università della Svizzera Italiana, Lugano, Schweiz
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5
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Post IORT seroma complication in breast cancer surgery. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Intraoperative radiotherapy (IORT) has gained popularity over recent years due to its impact on shortening the radiotherapy treatment time for early breast cancer. It has certainly proven effective as an exclusive treatment or when combined with whole breast irradiation (WBIR). Seroma is a common non-life-threatening complication that may delay treatment and impose challenges on radiological diagnostic follow-up.Aim:To review and compare the occurrence of seroma in patients who received exclusive IORT or when combined with WBIR and to outline the diagnostic challenges encountered during radiological follow-up.Materials and methods:Based on strict selection criteria, all eligible patients who received IORT ± WBIR treatment between 2012 and 2019 in a university hospital setting were included. Demographic data, histological diagnosis, tumour size, tumour grade, lymphovascular invasion, nodal status, receptor status, treatment with neoadjuvant hormonal chemotherapy, applicator size, dose used, duration of radiotherapy treatment, timing of seroma development and duration of seroma were documented. Both clinical and radiological follow-up were exercised in all patients.Results:The total number of patients treated with breast conserving surgery (BCS) and IORT was 86. Age ranged between 31 and 75 years with the median age of 51 years. Patients treated exclusively with IORT were 39 (45%) while those who received the IORT as a boost were 47 (55%). Seroma was observed in 39(45%) of both IORT and IORT\WBIR patients. Those included 15(38%) of the exclusive IORT treated patients and 24 (62%) of those treated as a boost. Duration of asymptomatic seroma ranged from 6 months to 6 years. Repeated aspiration was performed in 2 (5%) patients. Postoperative seroma occurred independent of age histological diagnosis, tumour size, tumour grade, lymphovascular invasion, nodal status, receptor status, treatment with neoadjuvant hormonal\chemotherapy, applicator size, dose used or duration of radiotherapy treatment. All reviewed patients have shown increased risk of developing seroma; however, an increased incidence of seroma in the IORT + WBIR treated patients was higher than those who received exclusive IORT treatment.Conclusion:Postoperative seroma is a common non-life-threatening entity that occasionally may lead to delay in the subsequent treatment plan. IORT is a safe modality with many benefits; however, it may increase the risk of seroma formation independent of the clinical parameters. Promoting the expertise in post IORT breast imaging aids in overcoming diagnostic challenges.
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Natarajan B, Spiegel D, Nichols EM, Feigenberg S, Blitzblau R, Broadwater G, Duffy EA, Baker JA, Horton JK. Findings on Surveillance Imaging After Preoperative Partial Breast Irradiation for Early Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2018; 102:1374-1381. [PMID: 30170870 PMCID: PMC6202155 DOI: 10.1016/j.ijrobp.2018.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the mammographic sequelae of preoperative accelerated partial breast irradiation (APBI) delivered via either stereotactic radiosurgery or a conventionally fractionated regimen. METHODS AND MATERIALS This multicenter, retrospective study evaluated surveillance mammograms from patients enrolled in 2 prospective, preoperative APBI clinical trials. At 1 site, 31 patients with cT1N0 invasive carcinomas or low- or intermediate-grade ductal carcinoma in situ (<2 cm) received preoperative stereotactic radiosurgery and had a total of 186 mammograms available for review. At the second site, 180 mammograms from 25 patients with cT1-2 (<3 cm) unifocal invasive carcinomas treated with conventionally fractionated, preoperative APBI were reviewed. Findings were compared with those of 26 early stage breast cancers treated with conventional postoperative whole breast radiation therapy. RESULTS At a median follow-up of 61 months, 17 patients (55%) treated with single-dose APBI exhibited exuberant fat necrosis at the lumpectomy site. Fat necrosis was believed to be clinically palpable in 5 (16%) of these patients within the first 3 years of follow-up. Exuberant fat necrosis developed in 5 patients (20%) treated with fractionated APBI over a median 68-month follow-up period but only 2 of those patients (8%) who underwent conventional whole breast radiation therapy. CONCLUSIONS In situ tumor targeting in the preoperative setting allows relative sparing of normal tissue but results in a larger and more vigorous area of change on surveillance imaging, potentially reflecting the interaction of surgical resection with an irradiated tissue bed. High-dose stereotactic radiosurgery in particular increases the risk of developing a uniquely robust and well-demarcated pattern of fat necrosis on mammogram that may also present clinically. With many ongoing studies evaluating the preoperative treatment approach, defining the landscape of expected imaging sequelae will provide useful anticipatory guidance for clinicians and patients.
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Affiliation(s)
- Brahma Natarajan
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Daphna Spiegel
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Steven Feigenberg
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rachel Blitzblau
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | | | - Eileen A Duffy
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jay A Baker
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Janet K Horton
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
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7
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Holmes DR, Zimmerman R. Intraoperative radiotherapy: Patient selection, management, and follow-up. J Surg Oncol 2017; 116:824-830. [PMID: 28715150 DOI: 10.1002/jso.24734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 05/29/2017] [Indexed: 01/19/2023]
Abstract
Intraoperative partial breast radiotherapy is an alternative or an adjunct to fractionated whole breast irradiation for the administration of adjuvant radiotherapy in breast cancer following breast conserving surgery. Establishing intraoperative radiotherapy as a therapeutic modality requires a multidisciplinary approach to patient selection, workup, surgery, radiation protocols, chemotherapy, and patient follow up. In this article, we review the published evidence for best clinical practice, as a guide to the introduction of intraoperative radiotherapy for breast cancer treatment.
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Affiliation(s)
- Dennis R Holmes
- The Margie Petersen Breast Center, John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, California
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8
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Multicatheter breast implant during breast conservative surgery: Novel approach to deliver accelerated partial breast irradiation. Brachytherapy 2016; 15:485-494. [DOI: 10.1016/j.brachy.2016.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 11/17/2022]
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9
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Falco M, Masojć B, Rolla M, Czekała A, Pietruszewska J, Rubik-Leszczyńska A, Lewocki M, Łukowiak M, Kram A. Risk factors for seroma evacuation in breast cancer patients treated with intraoperative radiotherapy. Rep Pract Oncol Radiother 2016; 21:225-31. [PMID: 27601955 PMCID: PMC5002024 DOI: 10.1016/j.rpor.2016.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/04/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Novel techniques in oncology provide new treatment opportunities but also introduce different patterns of side effects. Intraoperative radiotherapy (IORT) allows a shortened overall treatment time for early breast cancer either combined with whole breast radiotherapy (WBRT), or alone. Although the early side effects of IORT are well known, data on clinically important late side effects, which require medical intervention, are scarce. AIM In this study, we analyze risk factors for seroma evacuation more than 6 months after IORT. MATERIALS AND METHODS We evaluated 120 patients with a mean follow-up of 27.8 months (range: 7-52 months). Fifty-one patients received IORT only and 69 were additionally treated with WBRT. RESULTS Seroma evacuation was performed 6-38 months after IORT. Two (3.9%) events were observed in the IORT group and 14 (20%) in the IORT + WBRT group. Univariate (Kaplan-Meier) analysis showed that addition of WBRT to IORT increased the risk of seroma evacuation [hazard ratio = 5.5, 95% confidence interval: 2.0-14.7, P = 0.011]. In a multivariate analysis (Cox proportional hazards regression), WBRT and axillary lymph node dissection were significant risk factors for seroma evacuation (model P value = 0.0025). CONCLUSIONS WBRT applied after IORT is associated with increased risk of seroma evacuation, which might be considered as a late side effect.
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Affiliation(s)
- Michał Falco
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Bartłomiej Masojć
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Magdalena Rolla
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Agnieszka Czekała
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Jolanta Pietruszewska
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | | | - Mirosław Lewocki
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Magdalena Łukowiak
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Andrzej Kram
- Pathology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
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10
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Trifiletti DM, Jones R, Showalter SL, Libby BB, Brenin DR, Schroen A, Morris MM, Reardon KA, Showalter TN. Techniques for intraoperative radiation therapy for early-stage breast carcinoma. Future Oncol 2015; 11:1047-58. [DOI: 10.2217/fon.15.26] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
ABSTRACT Intraoperative radiation therapy (IORT) is a method of accelerated partial breast irradiation developed to replace other longer courses of radiotherapy with a single radiation session administered at the time of breast-conserving surgery. The purpose of this review is to summarize the advantages and disadvantages of breast IORT techniques that are currently available, as well to consider potential alternative techniques for breast IORT or ultra-short course breast radiotherapy. Furthermore, we highlight the published outcomes for the IORT treatment approaches including: electron therapy, superficial photon therapy and other techniques. Potential future directions of IORT are explored including novel IORT techniques utilizing intraoperative brachytherapy with in-room imaging and rapid treatment planning.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Ryan Jones
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Shayna L Showalter
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Bruce B Libby
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - David R Brenin
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anneke Schroen
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Monica M Morris
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kelli A Reardon
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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11
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Goble RN, Drukteinis JS, Lee MC, Khakpour N, Kiluk JV, Laronga C. Early experience with ultrasound features after intrabeam intraoperative radiation for early stage breast cancer. J Surg Oncol 2014; 109:751-5. [DOI: 10.1002/jso.23581] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 01/27/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Rachel N. Goble
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
| | | | - M. Catherine Lee
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
| | - Nazanin Khakpour
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
| | - John V. Kiluk
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
| | - Christine Laronga
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
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12
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Murawa P, Murawa D, Adamczyk B, Połom K. Breast cancer: Actual methods of treatment and future trends. Rep Pract Oncol Radiother 2014; 19:165-72. [PMID: 24936340 DOI: 10.1016/j.rpor.2013.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/04/2013] [Indexed: 01/17/2023] Open
Abstract
The recent ten to twenty years have seen a substantial progress in the diagnosis and treatment of breast cancer. A rapid development of various curative options has led to the improvement of treatment outcomes, while paying more and more attention to the aspects of quality of life and cosmetic effect. In our publication, we wish to outline certain trends in the development of modern treatment of breast cancer. Among topics discussed are new forms of molecular diagnostics, new approach to the idea of sentinel node biopsy, as well as new techniques for delivery of medical procedures, the increasing use of nomograms, progress in the techniques of breast conservative treatment, modern approach to occult breast lesions, the increasing use of neoadjuvant treatment and intraoperative radiotherapy.
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Affiliation(s)
- Paweł Murawa
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland ; Cancer Pathology Department, Oncology Department, Poznań University of Medical Sciences, Poland
| | - Dawid Murawa
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
| | - Beata Adamczyk
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
| | - Karol Połom
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
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13
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Elsberger B, Romsauerova A, Vinnicombe S, Whelehan P, Brown DC, Dewar JA, Thompson AM, Evans A. Comparison of mammographic findings after intraoperative radiotherapy or external beam whole breast radiotherapy. Eur J Surg Oncol 2013; 40:163-7. [PMID: 24332581 DOI: 10.1016/j.ejso.2013.11.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 11/14/2013] [Accepted: 11/15/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The TARGIT (TARGeted Intraoperative Radiotherapy) trial was designed to compare local recurrence and complication rates in breast cancer patients, prospectively randomised to either EBRT (external beam whole breast radiotherapy) or a single dose of IORT (intraoperative radiotherapy). The aim of our study was to compare follow-up mammographic findings, ultrasound and biopsy rates in each group. METHODS Follow-up imaging and breast biopsies of women from one centre participating in the TARGIT-A trial were independently reviewed by two radiologists blinded to the radiotherapy treatment received. RESULTS The cohort consisted of 141 patients (EBRT n = 80/IORT n = 61). There was no significant difference in the patient or disease characteristics of the two groups. The number of follow-up mammograms and length of follow-up was similar (EBRT/IORT n = 2.0/2.4; 4.3yr/5.1yr; p = 0.386 χ(2) test). There were no significant differences in mammographic scar or calcification appearances of the post-operative site. Generalised increase in breast density and skin thickening were more common in the EBRT compared to the IORT group (p = 0.002; p = 0.030, χ(2) test respectively). A trend towards additional ultrasound at follow-up was observed in the IORT group (15 of 61 [24.6%] versus 11 of 80 [13.8%]), however this was not statistically significant (p = 0.100 χ(2) test). No disease recurrence was demonstrated on any of the breast biopsies taken. Only one biopsy was reported as fat necrosis in the IORT group. CONCLUSIONS Mammographic changes were more common following EBRT, although more additional follow-up ultrasounds were performed in the IORT group. IORT is not detrimental to subsequent radiological follow up.
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Affiliation(s)
- B Elsberger
- Dundee Cancer Centre, Clinical Research Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.
| | - A Romsauerova
- Dundee Cancer Centre, Clinical Research Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - S Vinnicombe
- Dundee Cancer Centre, Clinical Research Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - P Whelehan
- Dundee Cancer Centre, Clinical Research Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - D C Brown
- Breast Unit, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - J A Dewar
- Dundee Cancer Centre, Clinical Research Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - A M Thompson
- Dundee Cancer Centre, Clinical Research Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - A Evans
- Dundee Cancer Centre, Clinical Research Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
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14
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Engel D, Schnitzer A, Brade J, Blank E, Wenz F, Suetterlin M, Schoenberg S, Wasser K. Are mammographic changes in the tumor bed more pronounced after intraoperative radiotherapy for breast cancer? Subgroup analysis from a randomized trial (TARGIT-A). Breast J 2012; 19:92-5. [PMID: 23173717 DOI: 10.1111/tbj.12049] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Intraoperative radiotherapy (IORT) with low-energy x-rays is increasingly used in breast-conserving therapy (BCT). Previous non-randomized studies have observed mammographic changes in the tumor bed to be more pronounced after IORT. The purpose of this study was to reassess the postoperative changes in a randomized single-center subgroup of patients from a multicenter trial (TARGIT-A). In this subgroup (n = 48) 27 patients received BCT with IORT, 21 patients had BCT with standard whole-breast radiotherapy serving as controls. Overall 258 postoperative mammograms (median follow-up 4.3 years, range 3-8) were retrospectively evaluated by two radiologists in consensus focusing on changes in the tumor bed. Fat necroses showed to be significantly more frequent (56% versus 24%) and larger (8.7 versus 1.6 sq cm, median) after IORT than those in controls. Scar calcifications were also significantly more frequent after IORT (63% versus 19%). The high incidence of large fat necroses in our study confirms previous study findings. However, the overall higher incidence of calcifications in the tumor bed after IORT represents a new finding, requiring further attention.
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Affiliation(s)
- Dorothee Engel
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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15
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Fat necrosis and parenchymal scarring after breast-conserving surgery and radiotherapy with an intraoperative electron or fractionated, percutaneous boost: a retrospective comparison. Breast Cancer 2012; 21:409-14. [DOI: 10.1007/s12282-012-0418-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 10/02/2012] [Indexed: 10/27/2022]
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16
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Wasser K, Schnitzer A, Engel D, Krammer J, Wenz F, Kraus-Tiefenbacher U, Suetterlin M, Schoenberg SO, Weisser G. First description of MR mammographic findings in the tumor bed after intraoperative radiotherapy (IORT) of breast cancer. Clin Imaging 2012; 36:176-84. [PMID: 22542375 DOI: 10.1016/j.clinimag.2011.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/27/2011] [Accepted: 08/30/2011] [Indexed: 11/28/2022]
Abstract
The aim was to investigate changes in the tumor bed on magnetic resonance mammography (MRM) after intraoperative radiotherapy (IORT) and whether they would limit the diagnostic value of posttherapeutic MRM. We retrospectively investigated 36 patients undergoing MRM after IORT (median interval 2.8 years, range 0.4-7.1). Wound cavities with fat necrosis were common after IORT (81%). They were associated with persisting contrast enhancement, i.e., enhancement was mostly seen irrespective of the posttherapeutic interval. It normally presented as rim enhancement and did not cause any diagnostic uncertainty if viewed together with other tissue characteristics. We do not expect a limited diagnostic value of MRM after IORT.
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Affiliation(s)
- Klaus Wasser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center, Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
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17
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Wenz F, Blank E, Welzel G, Hofmann F, Astor D, Neumaier C, Herskind C, Gerhardt A, Suetterlin M, Kraus-Tiefenbacher U. Intraoperative radiotherapy during breast-conserving surgery using a miniature x-ray generator (Intrabeam®): theoretical and experimental background and clinical experience. ACTA ACUST UNITED AC 2012; 8:39-47. [PMID: 22171773 DOI: 10.2217/whe.11.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Breast cancer is currently the most frequent indication for intraoperative radiotherapy with increasing numbers worldwide. Intraoperative radiotherapy can be used as a tumor bed boost followed by whole breast radiotherapy, or as a distinct form of accelerated partial breast irradiation in selected patients. This article summarizes the theoretical background including pattern of recurrence and distribution of tumor cell foci in the breast and discusses the rationale for intraoperative radiotherapy, especially using a miniature x-ray generator (Intrabeam(®)). The concepts of how to avoid geographic and temporal miss by giving radiotherapy during surgery to the open wound cavity are described. Experimental and clinical experience is presented based on in vitro experiments and more than 300 treated patients in a single department with mature follow-up.
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Affiliation(s)
- Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
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18
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Do structural changes in the tumour bed after intraoperative radiotherapy (IORT) of breast cancer complicate the evaluation of mammograms in a long-term follow-up? Eur J Radiol 2012; 81:e255-9. [DOI: 10.1016/j.ejrad.2011.02.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 02/02/2011] [Indexed: 11/19/2022]
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19
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Mammographic findings after intraoperative radiotherapy of the breast. Radiol Res Pract 2012; 2012:758371. [PMID: 22550585 PMCID: PMC3328171 DOI: 10.1155/2012/758371] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 11/04/2011] [Accepted: 11/07/2011] [Indexed: 12/14/2022] Open
Abstract
Intraoperative Radiotherapy (IORT) is a form of accelerated partial breast radiation that has been shown to be equivalent to conventional whole breast external beam radiotherapy (EBRT) in terms of local cancer control. However, questions have been raised about the potential of f IORT to produce breast parenchymal changes that could interfere with mammographic surveillance of cancer recurrence. The purpose of this study was to identify, quantify, and compare the mammographic findings of patients who received IORT and EBRT in a prospective, randomized controlled clinical trial of women with early stage invasive breast cancer undergoing breast conserving therapy between July 2005 and December 2009. Treatment groups were compared with regard to the 1, 2 and 4-year incidence of 6 post-operative mammographic findings: architectural distortion, skin thickening, skin retraction, calcifications, fat necrosis, and mass density. Blinded review of 90 sets of mammograms of 15 IORT and 16 EBRT patients demonstrated a higher incidence of fat necrosis among IORT recipients at years 1, 2, and 4. However, none of the subjects were judged to have suspicious mammogram findings and fat necrosis did not interfere with mammographic interpretation.
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